In many cases, insurance providers will contract with other companies to process the numerous insurance claims submitted by customers of the insurance provider. These companies, referred to as “insurance processors,” will receive policy information from the various insurance providers and then use this information to process the incoming claims. The policy information received may include, for example, information relating to one or more authorized providers (e.g., specific medical doctors or facilities, psychiatrists, etc.), the different benefits provided, and/or various eligibility requirements for each of the respective insurance policies offered by the insurance provider.
Because the insurance processor receives policy information from multiple sources (e.g., different insurance providers), it is often the case that the insurance processor will receive information in many different formats; each source, for example, having a different format for the policy information provided. For example, one insurance provider may designate the authorized providers using a five-digit numeric code. By contrast, another may use a seven-digit alphanumeric code. In addition, various insurance providers may have different ways of describing the fee schedule or method of calculating the benefit.
When an insurance processor receives policy information from various sources in various formats, it would be beneficial, and perhaps may even be necessary, for the insurance processor to be able to put all of the received information into a consistent format. The insurance processor may select a format that is used by a majority of the insurance providers, if such a format exists, or the insurance processor may have a particular format that is preferred or even necessary for use with the insurance processor's system.
A need, therefore, exists for enabling the insurance processor to efficiently and consistently reformat received insurance-related data into a consistent format that can be used when processing incoming insurance claims.
In addition, the policy information received by an insurance processor, such as the list of authorized providers and/or the various benefits and eligibility requirements, will often be in the form of, or in addition to, a set of complex rules and parameters to be used when processing the submitted insurance claims. These rules and parameters may be used to determine, for example, if the service on the claim is covered by the policy for the particular recipient, if there is a copay, coinsurance or other penalty, if the service is in or out of network, and/or which pricing methodology/fee schedule should be used to compute the allowed charges.
In a typical scenario, each parameter or rule of each insurance policy for each insurance provider would need to be translated into its own coding structure, or set of computer programming instructions. This can be very time consuming. Processing an insurance claim would then require running each set of computer programming instructions sequentially. In addition to being time consuming, this process may prevent a person who is unfamiliar with programming languages to ascertain whether or not the rule or parameter has been accurately translated. It further makes it difficult for the various rules or parameters to be changed at a later point in time, since this would likely require retranslating the entire rule or parameter into a new set of computer programming instructions.
A need, therefore, exists for an improved process of receiving incoming insurance policy information and converting the information, if necessary, into a format that can be easily understood and, if necessary, changed, yet still capable of being used by a claims processing engine when processing a submitted insurance claim.